IMPROVING DIABETIC PATIENTS’ ADHERENCE
TO TREATMENT PROGRAM BY USING
COMMUNITY BASED INTERACTIVE APPROACHDIABETES MELLITUS (CBIA-DM) STRATEGY IN
HOSPITAL BASED PATIENTS COMMUNITY
Titien Siwi Hartayu1 & 2, Aji Rustamaji2, Nurita Prasidayani2, Sri Suryawati2
1Faculty
of Pharmacy Sanata Dharma University, Indonesia
PhD candidate in Discipline of Social and Administrative Pharmacy Universiti Sains Malaysia
2 Centre for Clinical Pharmacology and Medicine Policy Studies Gadjah Mada University,
Indonesia.
Abstract
IMPROVING DIABETIC PATIENTS’ ADHERENCE TO TREATMENT PROGRAM BY USING COMMUNITY BASED INTERACTIVE APPROACHDIABETES MELLITUS (CBIA-DM) STRATEGY IN HOSPITAL- BASED PATIENTS COMMUNITY
Titien Siwi Hartayu1 & 2, Aji Rustamaji2, Nurita Prasidayani2, Sri Suryawati2
1Faculty of Pharmacy Sanata Dharma University, Indonesia
PhD candidate in Discipline of Social and Administrative Pharmacy Universiti Sains Malaysia
2 Centre for Clinical Pharmacology and Medicine Policy Studies Gadjah Mada University, Indonesia.
Problem Statement: As a chronic disease, diabetes-mellitus is a high risk in complications. In order to reduce diabetes-related complications,
adherence to treatment program is necessary. Unfortunately, adherence to treatment program of diabetic patients remains problematic. Therefore,
developed a strategy to improve diabetic patients’ adherence to treatment program by adapting the CBIA (Mothers’ Active Learning Method) is needed.
The new strategy is called CBIA-DM.
Objectives: To evaluate the impact of CBIA-DM strategy on diabetic patients’ knowledge, attitude, practice and adherence to treatment program.
Design: Intervention study, utilizing time series, pre and post quasi-experimental with control group study design.
Setting: The study was conducted in two charity hospitals in Yogyakarta, i.e.: Panti Rapih and Panti Rini hospitals. Panti Rapih DM club was selected
as intervention site and Panti Rini DM club was chosen as control site.
Study Population: Members of DM club, and/or their caregiver of Panti Rapih and Panti Rini hospitals.
Intervention: Small group discussion interactive approach in one session program with two hours duration of activities. The activities covered
introduction, active self-learning using CBIA-DM package, and wrap up and conclusion by DM experts. Data were collected at pre intervention,
immediately, 2 weeks and 4 weeks post intervention. Adherence to treatment program was assessed by calculating the number of remaining tablets on
the day pre test and post test, recording patients’ recall in diet, exercise and foot care practices per day and per week by nurses. Effectiveness of this
hospital-based patient community program in charity hospital setting was assessed based on the increasing of knowledge, attitude, practice,
adherence, intervention cost and acceptance of CBIA-DM by providers and participants; using Wilcoxon test, p < 0.005.
Policy: CBIA-DM strategy can be used as patients’ empowerment in hospital setting.
Outcome Measures: Knowledge, practice and adherence to treatment program, cost of intervention and acceptance of CBIA-DM program by the
head of diabetic club and participants
Results: CBIA-DM group significantly improved the knowledge score from 7.7 to 8.6 (p < 0.005) and practice from 4.6 to 6.0 (p < 0.005) with score
range 0-11, but not for the atttude score. Adherence increased from 30% vs. 16.7% at baseline, up to 46.7% vs. 23.3% at post 1 and 30% vs. 13.3% at
post 2. CBIA-DM program was conducted in two hours with unit cost US$ 4.00 per person cheaper than regular seminar in DM Club (US$ 8.00).
Participants and provider expressed that CBIA-DM was easy to be followed and enjoyable.
Conclusions: CBIA-DM package improved patients’ knowledge, practice and adherence to diabetes self-care. It is an effective strategy which is easy
to be followed and enjoyable. It is also feasible to be implemented in hospital-based setting as medium for RUM (Rational Use of Medicines)
education. However, improvement of the program is still needed to sustain the impact of the program.
Keywords: CBIA-DM, Diabetes Mellitus, Adherence, Hospital-based patients community, DM club.
BACKGROUND
Prevalence of type 2 diabetes increases globally*.
70% of diabetic patients lives in developing countries (Indonesia is the fourth rank) and is
estimated to be the fifth leading cause of death**
• Promotion of healthy life style is the most important factors in the health care
management***
• Physicians’ time for consultation is very limited
• Solution to accommodate diabetic patients’ information needs regarding their disease is
needed
 Non-adherence to treatment program is still as the main problem in diabetic patients****.
•
•
Special effort to improve the adherence to treatment program for people with
diabetes mellitus is urgently needed
____________________________________________________________________________
* Sutanegara, D., Budiarta, (2000) The epidemiology and management of diabetes mellitus in Indonesia [online]. [Accessed at 29th
October 2005]. Available from World wide web:http://www:ncbi.nlm.nih.gov/entrez/query.fcgl?cdm=retrieve&db
** Robles, YHK., Edwards AGK., Cannings-John, R., Butler, C.,(2007) Health education for diabetes mellitus type 2 in ethnic minority
groups (protocol). The Cochrane Library, 2, p.1-16
*** Ghazanfari, Z., Ghofranipour , F., Tavafian SS., Ahmadi, F., Rajab, A., (2007), Lifestyle education and diabetes mellitus type 2: A nonrandomized control trial, Iranian Journal Public Health, 36 (2).p. 68-72
****Rubin RR (2000) Diabetes and quality of life from research to practice/ diabetes and quality of life, diabetes spectrum [online] 13 (1)
[accessed 21 april 2006] p.21. available from world wide web:http://Journal.diabetes.org/diabetesspectrum/OOv13nl/pg21.html
Community-Based Interactive Approach (CBIA )
• Public education method, emphasizes on the active role of participants in looking for
information in small group discussion.
• Has been proven effective in improving knowledge and skills: in selecting OTC medicines
with impact in reducing OTC medicines in household*; of pharmacy assistant in
hypertension drug information service**; in improving patients’ adherence to take
medicines as recommended in tuberculosis***
CBIA is very potential to be developed as a model of public education in
other health issues, such as diabetes mellitus
DM club: as a hospital based patients community; has regular seminars every 2 months;
Sundays meeting and exercises together; and as a media for sharing experiences
_________________________________________________________________
*Suryawati, (2003), CBIA: Improving the quality of self-medication through mother active learning, Essential Drug monitor
Issuer, No. 32, p.22-23, WHO, Geneva.
**Astuti, A (1998) , Improving of knowledge and skill of Pharmacy assistant in hypertension drug information service
inYogyakarta munipalcity, by using CBIA methods. Master thesis. Postgraduate program of faculty of medicines
Gadjah Mada University.
***Susantini, A.,(2006), Improving tuberculosis patients’ adherence in taking medicine by using CBIA methods in Yogyakarta.
Master thesis. Postgraduate program of faculty of medicines Gadjah Mada University.
OBJECTIVES OF THE STUDY
General Objective
Measuring the impact of CBIA-DM on type 2 diabetic patients’ knowledge,
attitude, and practice towards diabetes self-care, as well as adherence to
treatment program
Specific objectives



To measure the impact of CBIA-DM on patients’ knowledge, attitude and
practice on diabetes self-care
To measure the impact of CBIA-DM on patients’ adherence to treatment
program
To evaluate in general the effectiveness of CBIA-DM strategy
METHODS
Study design:
This is a pilot implementation study, applying a pre and post quasi-experimental design. The
CBIA-DM intervention strategy was developed adapting the original CBIA* , enriched with
key messages to improve type 2 diabetic patients’ adherence to treatment program.
Setting:
Panti Rapih and Panti Rini hospitals are charity hospitals in Yogyakarta- Indonesia which
have diabetic clubs.
Two groups of DM club member and / or family member of 2 different hospitals
Intervention group : Underwent CBIA-DM (n=30)
Control group
: Underwent Sundays meeting and exercises
2 Monthly regulars seminar (n=30)
Inclusion criteria of study population:
Type 2 DM, DM club member and/or their family, literate, consented to the program and
completed all activities required over the study period
__________________________________________________________________________
*Suryawati, (2003), CBIA: Improving the quality of self-medication through mother active learning, Essential Drug monitor Issuer, No.
32, p.22-23, WHO, Geneva.
Selecting of the strategy:
 CBIA:
 Utilizing gathering forum
 Using training material
 Effective in improving skills
 Effective in improving TBC patients’ adherence
DM club: Diabetic patients gathering
High learning motivation
Needs for information
Problem: Non adherence
CBIA-DM
Modified to improve adherence to DM treatment
Improving diabetic patients’ adherence to treatment program.
Diabetic patients’ scheduled-visits to hospital was used as a
medium for rational used of medicines (RUM) education.
Developing of an educational material (CBIA-DM package)
Results of
FGD used for
drafting
educational
material.
Training of facilitators
1. Activities 2. Issues
Guideline
of DM
FGD among randomly
selected members of
diabetic club to obtain their
needs for information.
4. Healthy
3. About Lifestyle 5. Physical
Activities
DM
7. Diet
Program
6. Foot
Care
• Draft was
reviewed by
experts
• Pilot test of
the draft
among
selected
members of
DM club
CBIA-DM activities (2 hours):
1. Introduction:
 Explanation about
the steps of program
activities,
 Duration: 15 minutes
2. Small group discussion:
 6 participants in each group,
5 groups involved in the study
 Facilitator: trained pharmacy
students.
 Educational material:
CBIA-DM packages.
 Duration : 90 minutes.
3. Summary and
conclusion:
 By resource person.
 Duration: 15 minutes
Data collection and analysis
Data Collection:
 Using yes/no questions for knowledge level
 Practice indicators were assessed by patients’ diary and pill counting focus. When the
number of remaining tablets was the same as the number of tablets supposed to be left
on the counting date it was categorized as adhere.
 At 3 time points: pre intervention, post 2: week 2 and post 3: week 4 after intervention.
 Questionnaires were tested for validity by professionals’ (internist's, nutritionist and head
of diabetic club) opinion or judgement. Reliability test was conducted by using
Chronbach’s Alpha (α > 0.75).
 In-depth interviews were conducted among participants to obtain the impression
regarding the program intervention.
 Intervention cost was calculated based on resource person’s fee, refreshment, meeting
place and then compared to the cost of regular seminars in DM club (history)
Data analysis:
 Comparisons of knowledge and practice scores for each group were analyzed by using
Wilcoxon signed-rank test, while comparison of knowledge level between intervention
and control group were analyzed by using the Kruskal-Wallis test and Mann-Whitney test.
 All p values obtained less than α=0.05 were considered as statistically significant.
 All data are presented as descriptive analytic in tables and figures
RESULTS
1. Improvement of knowledge scores
2. Improvement of practice scores
11
10
8
6
4
2
0
9
*)
*)
7
CBIA
5
*)
3
Control
group
Pre test Post 2 (W+2) Post 3 (W+4)
3. Increasing number of participants
on adherence to treatment program
30
25
*)
10
5
0
Pre test
Pre test
Post 2 (W+2) Post 3 (W+4)
4. Time required for conducting CBIA-DM
program was 2 hours, with cost US$ 4
per person cheaper than regular
seminars in DM Club (US$ 8).
5. Participants and head of DM club
expressed their appreciation to the
program and mentioned that CBIA-DM
program is easy to be followed and is
enjoyable.
20
15
Control
group
1
-1
CBIA
Post 2 (W+2)
CBIA
Control group
Post 3 (W+4)
*) Wilcoxon test p < 0.05
Summary

CBIA-DM strategy showed significantly improved of diabetic knowledge, practice
and adherence to treatment program

Preparing training material was time consuming, however time required for
conducting CBIA-DM strategy was only 2 hours

Participants enjoyed all activities because the program was easy to be followed,
and lead to participants felt more confident with their condition.

Cost of intervention is cheaper than cost for conducting regular seminar in DM club

These results indicated that the CBIA-DM strategy was capable of improving the
adherence of participants in diabetes self-care
CONCLUSIONS and IMPLICATIONS
Conclusions:
 CBIA-DM program is an effective, economic and enjoyable strategy to improve type 2
diabetic patients’ adherence to treatment program and is feasible to be implemented in
hospital setting
 Repeating and developing the program is needed to sustain the impact of the CBIA-DM
strategy
Hospital-based patients community is possible to be used as a media for patients education
and improving rationale used of medicines (RUM)
Implications:
 CBIA-DM strategy can be used as patients’ empowerment in hospital setting
 CBIA-DM strategy can be used as a model for patients education in other chronic
disease.
RECOMMENDATIONS
CBIA-DM strategy will be successfully to be conducted in hospital-based patients
community, when the activity is supported by:
1) The health care providers and staff, which can be gotten by:
 clearly explain to them about the objectives and the advantages of the program
 follow the hospital’s policy and procedure
 use the hospital’s events and schedules
2) Participants, which can be gotten through conducting an interesting program including:
 educational material
 dynamic of the program activities
 duration of the program activities
 do not create something new; for example new activities or new schedule that
will lead to the participants’ inconvinience
ACKNOWLEDGEMENT
The authors would like to thank to:
 The WHO-SEARO and the Sanata Dharma University Indonesia for financial support.
 Prof.Dr. Mohamed Izham Mohamed Ibrahim at the Discipline of Social and
Administrative Pharmacy, School of Pharmaceutical Sciences University Sains
Malaysia for the invaluable guidance, inspirations and advices
 Director and staff of the Panti Rapih and Panti Rini hospitals in Yogyakarta Indonesia,
for the place permission to conduct the study
 All study participants and discussion facilitators who involved in this study
 This study has been presented in:
 The Inter country meeting of WHO-SEARO in New Delhi India, 13 – 15 July 2010,
Funded by: WHO-SEARO.
 The 2nd International conference on Pharmacy and advance Pharmaceutical
sciences, Gadjah Mada University Indonesia, 19-20 July 2011
Funded by: The Sanata Dharma University, Indonesia
contact person:
Titien Siwi Hartayu
titien_hartayu@yahoo.com